Orthopedic Coding Alert

Question: What should I look for in the documentation to distinguish primary and secondary osteoarthritis? For example, if the surgeon documents DJD of the knee, end stage, bone on bone, would this be primary?

Kentucky Subscriber

Answer: Primary osteoarthritis (OA) doesn't have a specific cause, such as disease or trauma. If the surgeon documents trauma or some known abnormality such as an infectious disease caused the OA, it's secondary.

So if the surgeon simply documents "DJD of the knee end stage, bone on bone," you don't have enough information to determine whether it's primary or secondary. (DJD, degenerative joint disease, is another term for OA.)

You should report 715.36 (Osteoarthrosis, localized, not specified whether primary or secondary; lower leg) in the case you describe.

-- Reader Questions and You Be the Coder were reviewed by Heidi Stout, CPC, CCS-P, director of orthopedic coding services at The Coding Network LLC; and Bill Mallon, MD, orthopedic surgeon and medical director at Triangle Orthopaedic Associates in Durham, N.C.